Provider Demographics
NPI:1972913234
Name:FAE, KHAILITHA (L AC, DOM)
Entity Type:Individual
Prefix:
First Name:KHAILITHA
Middle Name:
Last Name:FAE
Suffix:
Gender:F
Credentials:L AC, DOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1539 OREGON AVE
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86305-2225
Mailing Address - Country:US
Mailing Address - Phone:928-225-1655
Mailing Address - Fax:
Practice Address - Street 1:119 GARDEN ST STE B
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86305-2913
Practice Address - Country:US
Practice Address - Phone:928-225-1655
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-07
Last Update Date:2014-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0780171100000X
NM1020171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist